Payment Records Adjuster (Claims Support Specialist)

WPS Health Solutions New • Madison, WI

4d • Hybrid

About The Position

This position is responsible for correcting payment errors on a post-processing basis, including credits, additional payments, statistical adjustments, recoupments, correspondence, and patient or sponsor updates. The role requires U.S. Citizenship due to Department of Defense restrictions and the incumbent must live within 45 miles of the WPS Corporate Center Building in Madison, WI. The position supports services under U.S. Department of Defense (DoD) Defense Health Agency (DHA) contract(s) and is subject to federal regulations, DoD contract requirements, and WPS internal policies regarding data security, privacy, confidentiality, and program integrity. DoD contractors and their personnel are subject to screening and background investigation.

Requirements

• U.S. Citizenship is required for this position due to Department of Defense restrictions.
• High school diploma or equivalent.
• 1 or more years recent TRICARE claims entry (claims support) or processing OR 2 or more years office experience involving account reconciliations and customer contact including bookkeeping, billing, or financial services.
• Possess data entry and 10-key skills.
• Ability to learn and apply TRICARE benefits, Policy, Operations Manual, and federal regulations.
• Ability to learn TRICARE claims processing methodologies and systems in resolution of payment errors.
• Ability to interpret legal documents and documents from primary insurance.
• Wired (ethernet cable) internet connection from your router to your computer.
• High speed cable or fiber internet.
• Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection.

Responsibilities

• Correct payment errors on a post-processing basis, including credits, additional payments, statistical adjustments, recoupments, correspondence, and patient or sponsor updates.
• Identify and credit refunds to correct claim history.
• Contact beneficiaries, providers, and other agencies as necessary to obtain information to ensure refunds are posted to the correct account.
• Request recoupment of payments in accordance with TRICARE Policy and Operational Manual.
• Respond to correspondence from internal and external customers, including departments within MVH Division, attorneys, insurance companies, TRICARE Management Activity (TMA), government agencies, and prime contractors.
• Coordinate benefits with commercial insurance, Medicare, and other plans.
• Review computer-generated and inventory reports to prioritize workflow and ensure claims processing timeline standards are met.
• Report aging inventory concerns or system issues to supervisor or unit coordinator.
• Process adjustments and credits with an understanding of TRICARE Encounter Data editing requirements imposed by TMA.
• Review claims to determine if processing is correct according to the automated claims processing system’s methodology for pricing, reimbursement, and cost-sharing.
• Interpret legal documents for payments involving judgments such as custodial or bankruptcy.
• Make recommendations for process improvements by filing an Improvement Corrective Preventative Action (ICPA) and Potential Non-Conformance (PNC) forms.
• Complete Sponsor Patient Information Updates (SPIU) accordingly.

Benefits

• Performance bonus and/or merit increase opportunities
• 401(k) with dollar-per-dollar match up to 6% of salary (100% vested immediately)
• Competitive paid time off
• Health insurance, dental insurance, and telehealth services start DAY 1
• Employee Resource Groups
• Professional and Leadership Development Programs

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED